atherosclerosis and current anti-oxidant strategies for ... · atherosclerosis and current...

Chapter 1

Atherosclerosis and Current Anti-OxidantStrategies for Atheroprotection

Luigi Fabrizio Rodella and Gaia Favero

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53035

1. Introduction

Cardiovascular diseases (CVDs) remain the leading cause of death in modern societies. Theprimary cause of dramatic clinical events of CVDs, such as unstable angina, myocardial in‐farction and stroke, is the atherosclerotic process [1,2,3].

The pathophysiological mechanisms of atherosclerosis are complicated and the integratedpicture of the disease process is not yet complete, so currently is largely investigated. It iswidely recognized that oxidative stress, lipid deposition, inflammation, Vascular smoothmuscle cells (VSMCs) differentiation and endothelial dysfunction play a critical role in theformation, progression and eventually rupture of the atherosclerotic plaque [4]. Multiple riskfactors have been associated with the development of atherosclerotic lesions; these includediabetes mellitus, hypertension, obesity and tobacco smoking. The risk factors are influencedby genetic predisposition, but also by environmental factors, particularly diet. Moreover, ag‐ing promotes physiological changes, such as oxidative stress, inflammation and endothelialdysfunction strictly associated with the pathophysiology of atherosclerosis [5].

The common belief that signs of atherosclerosis and CVDs are clinically relevant only dur‐ing adult and elderly age is gradually changing, increasing evidence supports that athero‐genesis is initiated in childhood [6].

Low-density lipoproteins (LDL) are crucial to the development of atherosclerotic lesions,whereas high-density lipoproteins (HDL) are inhibitors of the process, primarily throughthe process of reverse cholesterol transport [4,7]. Dysfunctional lipid homeostasis plays acentral role in the initiation and progression of atherosclerotic lesions. Oxidized-LDL (ox-LDL) induces endothelial dysfunction with focal inflammation which causes increased ex‐pression of atherogenic signaling molecules that promote the adhesion of monocytes and T

© 2013 Fabrizio Rodella and Favero; licensee InTech. This is an open access article distributed under the termsof the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permitsunrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

lymphocytes to the arterial endothelium and their penetration into the intima. Early stagesof plaque development involve endothelial activation induced by inflammatory cytokines,ox-LDL and/or changes in endothelial shear stress [8,9]. The monocyte-derived macrophag‐es, by taking up ox-LDL, become foam cells, which are typical cellular elements of the fattystreak, the earliest detectable atherosclerotic lesion [10].

After initial injury, different cell types, including endothelial cells, platelets and inflammato‐ry cells release growth factors and cytokines that induce multiple effects: oxidative stress,inflammation, VSMCs differentiation from the contractile state to the active synthetic stateand then proliferate and migrate in the subendothelial space [11,12]. Inflammatory cell accu‐mulation, migration and proliferation of VSMCs, as well as the formation of fibrous tissue,lead to the enlargement and restructuring of the lesion, with the formation of an evident fi‐brous cap and other vascular morphological changes [2,13]. Atherosclerotic plaques resultfrom the progressive accumulation of cholesterol and lipids in oxidized forms, extracellularmatrix material and inflammatory cells [14]. In fact, atherosclerosis manifests itself histologi‐cally as an arterial lesions known as plaques, which have been extensively characterized:plaques contain a central lipid core that is most often hypocellular and may include crystalsof cholesterol that have formed in the foam cells. The lipid core is separated from the arteriallumen by a fibrous cap and myeloproliferative tissue that consists of extracellular matrixand VSMCs. Advanced lesions can grow sufficiently large to block blood flow and so devel‐op an acute occlusion due to the formation of thrombus or blood clot resulting in the impor‐tant and severe cardiovascular clinical events [2,10].

Figure 1. Main vascular alterations observed during atherogenesis. LDL: low density lipoprotein; HDL: high density lip‐oprotein.

Current Trends in Atherogenesis2

2. Atherosclerosis and oxidative stress

Oxidative stress is defined as an imbalance between pro-oxidant and anti-oxidant factors infavour of pro-oxidants and is central to the pathophysiology of atherosclerosis. The analysisof plaque composition has revealed products of protein and lipid oxidation, such as chlori‐nated, nitrated amino acids, lipid hydroperoxides, short-chain aldehydes, oxidized phos‐pholipids, F2α-isoprostanes and oxysterols [15].

Excessive production of reactive oxygen species (ROS) during oxidative stress, out strippingendogenous anti-oxidant defence mechanisms, has been implicated in processes in whichthey oxidize and damage DNA, protein, carbohydrates and lipids. There are multiple poten‐tial enzymatic sources of ROS, including mitochondrial respiratory cycle, heme, arachidonicacid enzyme, xanthine oxidase, nitric oxide synthese and others. However, the predominantROS-producing enzyme in the VSMCs and in the myocardium is NADPH oxidase, thatplays a pivotal role in the atherogenesis [16].

Figure 2. Generation and main damages induced by ROS. Modified from [17]. O2-: superoxide; HO`: hydroxyl; H2O2:

hydrogen peroxide..

ROS may contribute to LDL oxidation, inflammation, local monocyte chemoattractant pro‐tein production, upregulation of adhesion molecules and macrophages recruitment, endo‐thelial dysfunction, platelet aggregation, extracellular matrix remodelling through collagendegradation, thus playing a central role in the development and progression of atheroscle‐rosis and eventually in plaque rupture [17,18,19]. Several oxidative systems potentiallycontribute to LDL oxidation in vivo, included NADPH oxidases, xanthine oxidase, myelo‐

Atherosclerosis and Current Anti-Oxidant Strategies for Atheroprotectionhttp://dx.doi.org/10.5772/53035

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peroxidase, uncoupled nitric oxide synthase, lipoxygenases and mitochondrial electrontransport chain [20,21,22]. Ox-LDL particles exhibit multiple atherogenic properties, whichinclude uptake and accumulation of macrophages, as well as pro-inflammatory, immuno‐genic, apoptotic and cytotoxic activities, induction of the expression of adhesion moleculeson endothelial cells, promotion of monocyte differentiation into macrophages, productionand release of pro-inflammatory cytokines and chemokines from macrophages [14].

In particular, at endothelial level, ROS regulates numerous signaling pathways includingthose regulating growth, proliferation, inflammatory responses of endothelial cells, barrierfunction and vascular remodeling; while at VSMC level, ROS mediates growth, migration,matrix regulation, inflammation and contraction [23,24,25], all are critical factors in the pro‐gression and complication of atherosclerosis.

A vicious cycle between oxidative stress and oxidative stress-induced atherosclerosis leadsto the development and progression of atherosclerosis.

Figure 3. Role of ROS and oxidative stress in the atherosclerosis. Modified from [24]. O2: oxygen; O2-: superoxide; H2O2:

hydrogen peroxide; VSMC: vascular smooth muscle cell.


3. Atheroprotective strategies

Recently, various pharmacological therapies have been designed to reduce the developmentand progression of the atherosclerotic plaque and remarkable therapeutic advances in thetreatment of CVDs have been made with insulin sensitizers, statins, inhibitors of the renin-angiotensin system and anti-platelet agents [19,26]. However, strictly control of cardiovascu‐lar risk factors are often difficult to obtain and the progression of atherosclerosis has notbeen completely prevented with current pharmacological therapeutic options. Moreover,the modern evolution of Western societies seemingly steers populations towards a profoundsedentary lifestyle and incorrect diet is becoming difficult to reverse. Understanding of themechanisms that explain the fatal effects of physical inactivity and incorrect diet, the benefi‐cial effects of an healthy lifestyle remains largely unexplored [3].

Concerning atherosclerosis prevention by foods, dietary supplements and healthy life stylemay provide prevention and/or treatment to the onset and development of atherosclerosis.Development of an atheroprotective strategy acting on oxidative stress involved in thepathogenesis of atherosclerosis and with little toxicity or adverse effects may provide an ide‐al therapeutic treatment for atherosclerosis. Actually, numerous studies have investigatedthe prevention and treatment of atherosclerosis using naturally-occurring anti-oxidants.

In this review we summarize the many pieces of the puzzle to identified molecular targetsfor prevention and therapy against atherosclerosis and present that a healthy life style hasnatural anti-atherogenic activity which has been forgotten by modern societies.

Figure 4. Potential atheroprotective role of anti-oxidants in the atherogenic process. Modified from [27]. ox-LDL: oxi‐dized-low density lipoprotein; ROS: reactive oxygen species.


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4. Physical exercise

Physical activity is currently recognized as a potent tool for the prevention of chronic degen‐erative diseases, including CVDs and common tumors, such as those affecting the colon,breast, prostate and endometrium [28].

There is a body of clinical and experimental evidence showing that voluntary and imposedphysical exercise prevents the progression of CVDs and reduces cardiovascular morbidityand mortality. Therefore a physically active state is an appropriate and natural biologicalcondition for human and most animal species [3].

It has been demonstrated that exercise slows the progression of atherosclerosis, promotingits stabilization and preventing plaque rupture in a variety of hypercholesterolaemic animalmodels, such as apolipoproteinE-deficient mice and LDL receptor-deficient mice, whereasphysical inactivity accelerates it [3,29].

Exercise increases blood anti-oxidant capacity through elevating hydrophilic anti-oxi‐dants (uric acid, bilirubin and vitamin C) and decreases lipophilic anti-oxidants (carote‐noids and vitamin E) [28]. It is noteworthy that exercise prevents plaque vulnerabilityand atherosclerosis progression without necessarily correcting classic risk factors, such ashypercholesterolaemia, endothelial dysfunction and high blood pressure, suggesting thatexercise can directly affect plaque composition and phenotype, thus preventing the ap‐pearance of fatal lesions. Besides the effect of diet and drugs, the protective role of regu‐lar exercise against atherosclerosis is well established and its beneficial atheroprotectiveeffects are not limited to one particular cell, but to a variety of cells and tissues involvedin the pathogenesis of atherosclerosis and metabolic disorders, such as macrophages andadipose tissue [3].

Regular exercise and a correct diet would be natural atheroprotective approaches which hasbeen forgotten by modern societies.

5. Diet

Several epidemiological studies suggest that a correct diet is significantly associated withreduced risks of CVDs. Phytochemicals including polyphenols like flavonoids, resveratroland ellagitannins have been shown to be associated with lower risks of CVDs [30,31]. Infact, they are potent anti-oxidants and anti-inflammatory agents, thereby counteractingoxidative damage and inflammation. Actually, dietary anti-oxidants have attracted con‐siderable attention as preventive and therapeutic agents. There is adequate evidencefrom observational in vitro, ex vivo and in vivo studies that consumption of certain foodsresults to a reduction in oxidative stress [27]. Evidence linking dietary anti-oxidants toatherosclerosis in humans is still circumstantial and although in some studies the associa‐tion of anti-oxidant intake and low risk for atherosclerosis is perceptible, in others this


association cannot be established. The inconsistency of the results reflects the limitationsof human studies, the diet differences, the pre-existing total anti-oxidant status, the stageof disease, the interaction between dietary modulation and genetic composition of indi‐viduals, the dosage and duration of supplementation, the age and the sex. On the otherhand, studies in animal models of atherosclerosis clearly show an atheroprotective effectof dietary anti-oxidants, however, they focus mainly on early atherosclerotic events andnot in advanced atherosclerosis as in humans [27].

Cardiovascular prevention and treatment strategies should consider the simple, direct andinexpensive dietary approach as a first-line strategy to the burgeoning burden of CVDs,alone or in combination with pharmalogic treatments [10].

In this review we focus our attention on the main natural anti-oxidants contained in foodand on their primary diet source.

6. Polyphenol

Polyphenols are the most abundant anti-oxidants in human diet and are common constitu‐ents of foods of plant origin and are widespread constituents of fruits, vegetables, cereals,olive, legumes, chocolate and beverages, such as tea, coffee and wine [32,33].

They are defined according to the nature of their backbone structures: phenolic acids, flavo‐noids and the less common stilbenes and lignans. Among these, flavonoids are the mostabundant polyphenols in the diet [34]. Despite their wide distribution, the health effects ofdietary polyphenols have been attentively studied only in recent years [32] and several stud‐ies, although not all, have found an inverse association between polyphenol consumptionand CVDs motality [35].

Polyphenols exert anti-atherosclerotic effects in the early stages of atherosclerosis devel‐opment, they decrease LDL oxidation, improve endothelial function, increase vasorelaxa‐tion, modulate inflammation and lipid metabolism, improve anti-oxidant status andprotect against atherothrombotic events including myocardial ischemia and platelet ag‐gregation [35].

Many polyphenols have direct anti-oxidant properties, acting as reducing agents, andmay react with reactive chemical species forming products with much lower reactivity.Polyphenols may also affect indirectly the redox status by increasing the capacity of en‐dogenous anti-oxidants or by inhibiting enzymatic systems involved in ROS formation[36]. The free-radical scavenging activity of many polyphenols has been reported to bemuch stronger than that of vitamin C, vitamin E or glutathione, the major anti-oxidantspresent in the body.

In spite of their potent protective effects in the development of atherosclerosis, little isknown about aortic distribution of polyphenols [34].


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Figure 5. Main atheroprotective mechanisms exert by polyphenols. VSMC: vascular smooth muscle cell; LDL: low den‐sity lipoprotein; ROS: reactive oxygen species.

6.1. Resveratrol

Resveratrol naturally occurs as a polyphenol found in grapes and grape products, includingwine, as well as other sources, like nuts [37]. In grapes, resveratrol is present in the skin asboth free resveratrol and piceid.

Initially characterized as a phytoalexin, a toxic compound produced by higher plants in re‐sponse to infection or other stresses, such as nutrient deprivation, resveratrol attracted littleinterest until 1992 when it was postulated to explain some of the cardioprotective effects ofred wine [36].

Treatment with resveratrol has been found to reduce oxidative stress and increase the activi‐ties of several anti-oxidant enzymes including superoxide dismutase, catalase, glutathione,glutathione reductase, glutathione peroxidase and glutathione-5-transferase [38]. Resvera‐trol also prevents the oxidation of polyunsaturated fatty acids found in LDL and inhibits theox-LDL uptake in the vascular wall in a concentration-dependent manner, as well as pre‐vents damage caused to lipids through peroxidation [38]. These effects were found to bestronger respect the well known anti-oxidant vitamin E. Moreover, resveratrol has been pro‐posed to influence and maintain a balance between production of vasodilatators and vaso‐costrictors respectively [38,39], thereby preventing platelet aggregation and oxidative stress,which leads to reduction in CVD risk [40].


Resveratrol so has been demonstrated to exert a variety of health benefits including anti-atherogenic, anti-inflammatory and anti-tumor effects. These positive effects are attributedmainly to its anti-oxidant and anti-coagulative properties.

Figure 6. Main atheroprotective mechanisms exert by resveratrol. LDL: low density lipoprotein; HDL: high density lipo‐protein; ROS: reactive oxygen species.

Resveratrol reduced not only vascular lipid levels, including LDL and triglycerides, but alsothe myocardial complications by influencing infarct size, apoptosis and angiogenesis. In ad‐dition, resveratrol feeding prevented steatohepatitis induced by atherogenic diets throughmodulation of expression of genes involved in lipogenesis and lipolysis, reduced total andLDL levels, while increasing HDL levels in plasma.

Several investigations with human and various animal model have demonstrated an ab‐sence of toxic effects after supplementation with resveratrol across a wide range of dos‐ages [38].

Promising findings by several groups have demonstrated the potential cardioprotection ofresveratrol by reducing atherosclerotic plaque onset and formation.


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6.2. Flavinoid

Flavonoids, many of which are polyphenolic compounds, are believed to be beneficial forthe prevention and treatment of atherosclerosis and CVDs mainly by decreasing oxidativestress and increasing vasorelaxation [32,40,41]. More than 8.000 different flavonoids havebeen described and since they are prerogative of the kingdom of plants, they are part ofhuman diet with a daily total intake amounting to 1 g, which is higher than all otherclasses of phytochemicals and known dietary anti-oxidants. In fact, the daily intake of vita‐min C, vitamin E and β-carotene from food is estimated minor of 100 mg. A number of dif‐ferent factors, such as harvesting, environmental factors and storage, may affect thepolyphenol content of plants. Additional variability in flavonoid content could be expectedin finished food products because its availability is largely dependent on the cultivar type,geographical origin, agricultural practices, post-harvest handling and processing of the fla‐vonoid containing ingredients [32].

Flavonoids are widely distributed in the plant and are categorized as flavonol, flavanol, fla‐vanone, flavone, anthocyanidin and isoflavone. Quercetin is one of the most widely distrib‐uted flavonoids, which are abundant in red wine, tea and onions. Quercetin intake istherefore suggested to be beneficial for human health and its anti-oxidant activity shouldyield a variety of biological effects.

The major flavanols in the diet are catechins. They are abundant in green tea (about 150mg/100ml) and lesser extent in black tea (13.9 mg/100 ml) where parent catechins are oxidizedinto complex polyphenols during fermentation. Red wine (270 mg/L) and chocolate (blackchocolate: 53.5 mg/100 g; milk chocolate: 15.9 mg/100 g) are also sources of catechins [34].

Polyphenols and/or flavonoids exhibit a variety of beneficial biological effects, including an‐ti-oxidant, anti-hypertensive, anti-viral, anti-inflammatory and anti-tumor activities; more‐over some flavonoids have also been reported to modulate insulin resistance, endothelialfunction and apoptosis [32,41].

Many studies have shown that flavonoids demonstrate protective effects against the initia‐tion and progression of atherosclerosis. The bioactivity of flavonoids and related polyphe‐nols appears to be mediated through a variety of mechanisms, though particular attentionhas been focused on their direct and indirect anti-oxidant actions. In particular, it has beenshown that the consumption of flavinoids limits the development of atheromatous lesions,inhibiting the oxidation of LDL, which is considered a key mechanism in the endothelial le‐sions occurring in atherosclerosis.

Mechanisms of anti-oxidant effects include also: suppression of ROS formation either by in‐hibition of enzymes or chelating trace elements involved in free radical production, scavengROS and upregulation or protection of anti-oxidant defences [32]. The phenolic hydroxylgroups of flavonoids, which act as electron donors, are responsible for free radical scaveng‐ing activity [27,40].


Since the evidence of therapeutic effects of dietary flavinoids continues to accumulate, flavi‐noids could be considered as anti-oxidant nutrients available in everyday life as a protectivetool for prevention of atherosclerosis.

Figure 7. Main atheroprotective mechanisms exert by flavinoids. LDL: low density lipoprotein.

7. Green tea

Tea, a beverage consumed worldwide, is a source of both pleasure and healthful benefits.Originally recommended in traditional Chinese medicine, green tea (Camellia sinensis) hasgained considerable attention due to its anti-oxidant, anti-inflammatory, anti-hypertensive,anti-diabetic and anti-mutagenic properties [42].

Green tea constitutes 20%-22% of tea production and is principally consumed in China, Ja‐pan, Korea and Morocco. Green tea, or non-fermented tea, contains the highest amount offlavonoids, in comparison to its partially fermented (oolong tea) and fermented (black tea)counterparts and, due to its high content of polyphenolic flavonoids, has shown unique car‐diovascular health benefits. In green tea, catechins comprise 80% to 90% of total flavonoids,with epigallocatechin gallate, being the most abundant catechin (48–55%), followed by epi‐


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gallocatechin (9–12%), epicatechin gallate (9–12%) and epicatechin (5–7%) [42]. The catechincontent of green tea depends on several factors including how the leaves are processed be‐fore drying, preparation of the infusion and decaffeination, as well as the form in which it isdistributed in the market (instant preparations, iced and ready-to-drink teas have beenshown to contain fewer catechins) [43]. When tea leaves are rolled or broken during indus‐try manufacture, catechins come in contact with polyphenol oxidase, resulting in their oxi‐dation and the formation of flavanol dimers and polymers known as theaflavins andthearubigins [44].

Tea leaves destined to become black tea are rolled and allowed to ferment, resulting in rela‐tively high concentrations of theaflavins and thearubigins and relatively low concentrationsof catechins. Consequently, green tea contains relatively high concentrations of catechinsand low concentrations of theaflavins and thearubigins. It is important to underline thatblack tea administration to LDL receptor-deficient mice did not affect aortic fatty streak le‐sion area, although fatty streak lesion areas in the same animal model supplemented withanti-oxidants, such as vitamin C, vitamin E and β-carotene, were 60% smaller than those ofcontrol animals [44,45]. On the other hand, green tea catechins have been shown to inhibitformation of ox-LDL, may decrease linoleic acid and arachidonic acid concentrations [46],elevate serum anti-oxidative activity and prevent or attenuate decreases in anti-oxidant en‐zyme activities [44]. In addition to having anti-oxidant properties, green tea catechins havealso been shown to reduce VSMCs proliferation [42].

In particular, Erba et al. (2005) showed a significant decrease in plasma peroxide levels,DNA oxidative damage and LDL oxidation, as well as a significant increase in total anti-oxi‐dant activity in the plasma of healthy volunteers who consumed two cups of green tea perday in addition to a balanced and controlled diet demonstrating that green tea may act syn‐ergistically with a correct diet in affecting the biomarkers of oxidative stress [47]. Much ofthe evidence supporting anti-oxidant functions of tea polyphenols is derived from assays oftheir anti-oxidant activity in vitro. However, evidence that tea polyphenols are acting direct‐ly or indirectly as anti-oxidants in vivo is more limited [44].

It is very important to underline also that while green tea beverage consumption is con‐sidered part of a healthy lifestyle, green tea extracts supplements should be used withcaution. Very high doses of green tea extracts (6 g–240 g) have been associated with hepa‐totoxicity in patients who used them for a duration of 5 to 120 days, changing in blood bi‐ochemical parameters included an elevation of serum levels of aspartate aminotransferase,alanine aminotransferase, alkaline phosphatase, total bilirubin and albumin levels. Al‐though, it was observed a reversal of symptoms when subjects stopped taking the greentea supplement [42].

In addition, in a number of countries, tea is commonly consumed with milk. Interactions be‐tween tea polyphenols and proteins found in milk have been found to diminish total anti-oxidant capacity in vitro, but it is presently unclear whether consuming tea with milksubstantially alters the biological activities of tea flavonoids in vivo. The addition of milk totea did not significantly alter areas under the curve for plasma catechins or flavonols in hu‐man volunteers, suggesting that adding milk to tea does not substantially affect the bioavail‐


ability of tea catechins or flavonols. Two studies in humans found that the addition of milkdecreased or eliminated increase in plasma anti-oxidant capacity induced by tea consump‐tion, whereas another found no effect [44].

Nevertheless, a diet rich in foods containing anti-oxidant polyphenols, like green tea bever‐ages, combined with physical activity and a correct diet may offer primary preventionagainst CVDs. While future clinical trials could further elucidate the cardioprotective bene‐fits of green tea beverages, on the basis of existing reports, freshly prepared green tea ap‐pears to be a healthy dietary choice to consider as an atheroprotective strategy.

8. Herbal

Studies of the herbal medicines for the prevention and treatment of atherosclerosis have re‐ceived much attention in recent years. Single compounds isolated from some herbal materi‐als have been shown to reduce the production or remove the build up of cholesterol in vitroor in vivo studies. Glabrol from Glycyrrhiza glabra has been found to be an acyl-coenzymeA: a cholesterol acyltransferase inhibitor that blocks the esterification and intestinal absorp‐tion of free cholesterol. Curcumin from Curcuma longa inhibited cholesterol accumulation.Puerarin from Pueraria lobata can promote cholesterol excretion into bile by upregulatingthe rate-limiting enzyme in the synthesis of bile acid from cholesterol. Moreover, these ex‐tracts have anti-oxidative effects and may reduce the levels of ox-LDL and increased the lev‐els of HDL [48].

9. Pomegranate juice

Pomegranate juice consumption slowed atherosclerosis progression through the potent anti-oxidant properties of pomegranate polyphenols [35].

Pomegranate fruit (Punica granatum L.) has been rated to contain the highest anti-oxidant ca‐pacity in its juice, when compared to other commonly consumed polyphenol rich beverages.The anti-oxidant capacity of pomegranate juice was shown to be three times higher than thatof red wine and green tea, based on the evaluation of the free-radical scavenging and ironreducing capacity [30]. It was also shown to have significantly higher levels of anti-oxidantsin comparison to commonly consumed fruit juices, such as grape, cranberry, grapefruit ororange juice. The principal anti-oxidant polyphenols in pomegranate juice are ellagitanninsand anthocyanins. Ellagitannins account for 92% of the anti-oxidant activity of pomegranatejuice and are concentrated in peel, membranes and piths of the fruit. The bioavailability ofpomegranate polyphenols is affected by several factors, including: interindividual variabili‐ty, differential processing of pomegranate juice, as well as the use of analytical techniquessensitive enough to detect low postprandial concentrations of these metabolites [30].

One pomegranate fruit contains about 40% of an adult’s recommended daily requirement ofvitamin C and is high in polyphenol compounds. The pomegranate plant contains alkaloids,


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mannite, ellagic acid and gallic acid and the bark and rind contain various tannins. The pol‐yphenols in pomegranate are believed to provide the anti-oxidant activity and protect LDLagainst cell-mediated oxidation directly by interaction with the LDL [49]. In fact, the supple‐mentation of pomegranate juice revealed a significant reduction in the atherosclerotic lesionarea compared to the water-treated group reporting significant anti-oxidant capacities of allpomegranate extracts.

The principal mechanisms of action of pomegranate juice may include: increased serum an‐ti-oxidant capacity, decreased plasma lipids and lipid peroxidation, decreased ox-LDL up‐take by macrophages, decreased intima-media thickness, decreased atherosclerotic lesionareas, decreased inflammation and decreased systolic blood pressure, thereby reducing/inhibiting the progression of atherosclerosis and the subsequent potential development ofCVDs [30,50].

On the basis of limited safety data, high doses of pomegranate polyphenol extracts mayhave some deleterious effects: gastric irritation, allergic reactions, including pruritus, urtica‐ria, angioedema, rhinorrhea, bronchospasm, dyspnea and red itchy eyes. Moreover, driedpomegranate peel may contain aflatoxin, a potent hepatocarcinogen; thus, it should be usedcautiously by patients who have hepatic dysfunction or who are taking other hepatotoxicagents. Pomegranate may also increase the risk for rhabdomyolysis during statin therapy, asa result of intestinal CYP3A4 inhibition and increased absorption of active drugs [49].

10. Wine

The last two decades have seen renewed interest in the health benefits of wine, as documentedby increasing research and several epidemiologic observations showing that moderate winedrinkers have lower cardiovascular mortality rates than heavy drinkers or teetotalers. Most ofthe beneficial effects of wine against CVDs have been attributed to the presence in red wine ofresveratrol and other polyphenols. Wines contain polyphenolic compounds that can be rough‐ly classified in flavonoid and non flavonoid compounds; both classes of compounds have beenimplicated in the protective effects of wine on the cardiovascular system. Resveratrol is one ofthe most biologically active polyphenols contained in wine.

Moderate wine intake reduces cardiovascular risk [51]. In addition, it is known that alcoholfavourably modifies the lipid pattern by decreasing total plasma cholesterol, in particularLDL, and by increasing HDL. Cardiovascular risk reduction seems to be linked largely tothe effect of non-alcoholic components, mainly resveratrol and other polyphenols, on thevascular wall and blood cells and a great part of the beneficial effects of resveratrol on vas‐cular function are due to its anti-oxidant effects.

The effect of resveratrol and other wine polyphenols on oxidative stress has been scarcelyexplored in humans and only a few studies have analyzed the effects of wine supplementa‐tion on indexes of oxidation in vivo [36].


Figure 8. Main polyphenols in wine. * Polyphenols contained only in white wine. Modified from [36].

11. Olive oil

A high intake of some unsaturated fatty acid and/or anti-oxidant compounds can both re‐duce pro-atherogenic risk factors and the susceptibility of the vascular wall to pro-inflam‐matory and pro-atherogenic triggers.

Many Authors started to recognize olive oil as one of the key elements in the cardioprotec‐tion and longevity of inhabitants of Mediterranean regions. The healthful properties of oliveoil have been often attributed to its high content of monounsaturated fatty acids, namelyoleic acid [7]. However, it should be underlined that olive oil, unlike other vegetable oils,contains high amounts of several micronutrient constituents, including polyphenolic com‐pounds (100– 1000 mg/kg) [10].

The major phenolic compounds in olive oil are: simple phenols (i.e., hydroxytyrosol, tyro‐sol); polyphenols (oleuropein glucoside); secoiridoids, dialdehydic form of oleuropein andligstroside lacking a carboxymethyl group and the aglycone form of oleuropein glucosideand ligstroside and lignans. Around 80% or more of the olive oil phenolic compounds arelost in the refination process, thus, their content is higher in virgin olive oil (around 230 mg/kg) than in other olive oils.

Olive oil supplementation (50 mg/day) to the diet enriched LDL with oleic acid and signifi‐cantly reduced human LDL susceptibility to in vitro oxidation, thus making them signifi‐cantly less atherogenic. In part, this reflects the lesser susceptibility of monounsaturatedfatty acids to lipid peroxidation compared with that of polyunsaturated fatty acids, whichare particularly prone to peroxidation due to the greater number of double bonds [10,52].

Olive oil consumption could reduce oxidative damage, on one hand, due to its richness inoleic acid and, on the other hand, due to its minor components of the olive oil particularly


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the phenolic compounds. The phenolic content in virgin olive oil could reduce the lipid oxi‐dation and inhibit platelet-induced aggregation [53].

Moreover, olive oil minor components have also been involved in the anti-oxidant activityof olive oil. Some components of the unsaponifiable fraction, such as squalene, β-sitosterolor triterpenes, have been shown to display anti-oxidant and chemopreventive activities andcapacity to improve endothelial function decreasing the expression of cell adhesion mole‐cules and increasing vasorelaxation [54].

Olive oil phenolic compounds are able to bind the LDL lipoprotein and to protect other phe‐nolic compounds bound to LDL from oxidation. The role of phenolic compounds from oliveoil on DNA oxidative damage remains controversial and perhaps more sensitive methodswould be required to detect differences among the types of olive oil consumed. Furtherstudies are required to establish the potential benefits of olive oil and those of its minor com‐ponents on DNA oxidative damage.

One of the most well known and important characteristic of the Mediterranean diet is thepresence of virgin olive oil as the principal source of energy from fat. In contrast to otheredible oils with a similar fatty composition, like sunflower, soybean and rapeseed canolaoils, virgin olive oil is a natural juice, while the seed oils must be refined before consump‐tion, thus changing its original composition during this process. Virgin olive oils are thoseobtained from the olives solely by mechanical or other physical means under conditions thatdo not lead alteration in the oil. The olives have not undergone any treatment other thanwashing, decantation, centrifugation or filtration [53].

Virgin olive oil is a source of healthy unsaturated fatty acids and hundreds of micronu‐trients, especially anti-oxidants, as phenol compounds, vitamin E and carotenes.

Results of the randomized cross-over clinical trials performed in humans on the anti-oxidanteffects of olive oil phenolic compounds are controversial. The protective effects on lipid oxi‐dation in these trials have been better displayed in oxidative stress conditions, i.e. males,submitted to a very strict anti-oxidant diet, hyperlipidaemic or peripheral vascular diseasepatients. Carefully controlled studies in appropriate populations, or with a large samplesize, are urgently required to definitively establish the in vivo anti-oxidant properties of theactive components of virgin olive oil [55].

12. Oligoelements in water

Epidemiological studies have revealed both a higher incidence of CVDs and cerebrovascularmortality in soft water areas and a negative correlation between water hardness and cardio‐vascular mortality [56,57]. Actually, there is not enough evidence to determine whether hardwater contains protective substances not present in soft water or if there are detrimentalsubstances in soft water.

Water contains oligominerals, such as calcium, magnesium, cobalt, lithium, vanadium, sili‐con, copper, iron, zinc and manganese, that are some important factors in reducing the risk


of CVD onset. On the other hand, elements like cadmium, lead, silver, mercury and thalliumare considered to be harmful [58].

Magnesium deficiency is considered to be a risk factor of CVDs, in fact its supplementationdelays the onset of atherosclerosis or hinders its development. On the other hand, silicon is amajor trace element in animal diets and humans ingest between 20-50 mg/day of siliconwith the Western diet [59]. Main dietary sources are whole grain cereals and their products(including beer), rice, some fruits and vegetables and drinking water, especially bottled min‐eral waters with geothermal and volcanic origin [60]. Numerous studies showed that siliconhas a role in maintaining the integrity, the stability and the elastic properties of arterial walls[61,62] and postulated silicon as a protective factor against the development of age-linkedvascular diseases, such as atherosclerosis and hypertension [62,63].

In addition, vanadium is considered to have anti-atherosclerotic properties; lithium can alsoinhibit the synthesis of cholesterol, but has an atherogenous activity that can be inhibited bysupplementation with appropriate quantities of calcium. A copper-deficient diet can inducehypercholesterolemia and hypertriglyceridemia that is, in turn, intensified by high levels ofdietary zinc [58,64].

On the basis of these limited data, intakes of silicon, magnesium and vanadium in water andavoiding exposure to cadmium and lead are important elements of the prophylaxis ofCVDs, so hard water has positive health effects and should not be replaced by drinking wa‐ter with insufficient amounts of beneficial elements [58]. It is important to remember alsothat water has small contribution of mineral trace respect to total dietary intake (7% fromliquid vs 93% from solid food) [58,65].

13. Melatonin supplementation

Melatonin, an endogenously produced indoleamine, is a remarkably functionally pleiotropicmolecule [66] which functions as a highly effective anti-oxidant and free radical scavenger[67,68]. Endogenously produced and exogenously administered melatonin has beneficial ac‐tions on the cardiovascular system [69,70,71].

Exogenously administered melatonin is quickly distributed throughout the organism; it maycross all morphophysiological barriers and it enters cardiac and vascular cells easily. High‐est intracellular concentration of melatonin seem to be in the mitochondria; this is especiallyimportant as the mitochondria are a major site of free radicals and oxidative stress genera‐tion. Moreover, melatonin administration in a broad range of concentration, both by the oraland intravenous routes, has proven to be safe for human studies [72,73].

Melatonin itself appears to have an atheroprotective activity during LDL oxidation and alsomelatonin’s precursors and breakdown products inhibit LDL oxidation, comparable to vita‐min E. Because of its lipophilic and nonionized nature, melatonin should enter the lipidphase of the LDL particles and prevent lipid peroxidation [9] and may also augments en‐dogenous cholesterol clearance.


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Melatonin also counteracts the cell oxidative burden indirectly by stimulating the produc‐tion of cell ROS detoxifying enzymes, specially glutathione peroxidase, glutathione reduc‐tase and superoxide desmutase. Melatonin besides being a more effective anti-oxidant thanresveratrol can reverse the pro-oxidant DNA damage induced in low concentration of re‐sveratrol, when added in combination [74].

Moreover, 6-hydroxymelatonin, the main in vivo metabolite of melatonin, and its precursor,N-acetyl-5-hydroxytryptamine, were potent in reducing in vitro LDL peroxidation. The abili‐ty of the parent molecule melatonin as well as its metabolites to function in radical detoxifi‐cation greatly increases its ability to limit oxidative abuse at many levels within cells [9].Therefore it can be suggested that although melatonin per se would have physiologically orpharmacologically effects to inhibit in vivo LDL oxidation, its action sinergically with itsmain catabolite would be more active [75]. Melatonin may exert protective and benefical ef‐fects against CVDs reducing the risk of atherosclerosis and hypertension [9].

It is important to underline that the recent discovery of melatonin in grapes [74] opens newpespectives in the field of natural anti-oxidative atheroprotective strategies.

14. Vitamins

Vitamin C is a water-soluble vitamin and is believed to regenerate vitamin E from its oxi‐dized state back to its activated state. The principal sources of vitamin C are citrus fruits,tomatoes and potatoes. Natural vitamin E is a mixture of tocopherols and tocotrienols syn‐thesized only by plants and the natural sources are vegetal oils. In fact, olive oil contains vi‐tamin E and many of its beneficial effects are attributed to this constituent.

Vitamin E acts as a chain-breaking anti-oxidant for LDL lipids [27]. In vitro enrichment ofLDL in vitamin E drastically increases their resistance to oxidative stress and it has also beenreported to inhibit the cytotoxicity of ox-LDL toward cultured endothelial cells. Vitamin Ehas been reported to retard atherosclerosis progression in certain arteries of primates fed anatherosclerosis diet. In humans, both women and men, exhibited reduced vascular diseaseparameters [75], beneficial effects in the reduction of risk of onset and progression of athero‐sclerosis, due to its inhibition of LDL oxidation and association with molecular modulationof the interaction of immune and endothelial cells. A long term supplementation with vita‐min E in hypercholesterolemic patients and/or chronic smokers increase levels of autoanti‐bodies against ox-LDL. There is also a quite convincing evidence from in vitro studies thatvitamin C strongly inhibits LDL oxidation [27].

It is important to underline that there are no definite recommendations on the dose and du‐ration of supplementation with vitamins in human. Although, high dietary intake of fruitand vegetables is associated with a reduction in the incidence of atherosclerosis, stroke andcardiovascular mortality in general [27]. Moreover, epidemiologic studies have reportedthat high dietary intake of foods rich in vitamin E, vitamin C and β-carotene have been in‐versely associated with the incidence of CVDs [35].


Actually, it is difficult to conclude that a clinical benefit of anti-oxidants in CVD is estab‐lished. Thus, it is necessary to clarify why anti-oxidants showed their beneficial effects invitro, whereas less satisfactory results were observed in some, although not all, clinicalconditions [40].

15. HDL-based diet

It is well known that LDL are crucial to the development of atherosclerotic lesions, whereasHDL are inhibitors of the process, so the primary focus of pharmaceutical lipid modulationis reduced LDL; this strategy has reduced cardiovascular morbidity and mortality by up to25% [76].

Recent studies also suggest that HDL inhibits oxidation, prevents the expression of inflam‐matory mediators and the expansion of pro-atherogenic myeloid cells and reduces the ex‐pression of pro-coagulant enzymes, each of which may contribute in smaller ways toatheroprotective effects [77].

The synthesis and release of HDL into the peripheral vasculature is the first step in reversecholesterol transport that is proposed to be a major mechanism by which HDL mediates itsatheroprotective effects [78]. However, HDL possesses multiple anti-atherosclerotic proper‐ties in addition to reverse cholesterol transport. HDL acts as a transporter of a variety of fat-soluble vitamins, including vitamin E, and also as a natural anti-oxidant protecting for LDLin a multifactorial manner. Moreover, HDL are associated with enzymes with anti-oxidantcapacity, like paraoxonase that is a major contributor to the anti-oxidant activity of HDL[78]. Paraoxonase is synthesized in the liver and released into the circulation, where it be‐comes closely associated with HDL.

HDL has also been demonstrated to improve endothelial function, maintain the integrity ofvascular endothelium and may induce the production of vasodilators, such as prostacyclin,by the endothelium. HDL has also been demonstrated to exhibit anti-thrombotic and anti-inflammatory activities.

The combination of a low saturated fat diet and increased exercise raises HDL levels by 5–14% and lowers triglyceride, LDL and total cholesterol levels by 4–18%, 7–15% and 7-18%,respectively. Thus, simple lifestyle measures including a correct diet and increased activityrepresent a cost-effective and low-risk intervention that is associated with a range of healthbenefits [76].

There is considerable interest at present in the possible therapeutic effects of elevating HDLlevels to capitalize on their vasculoprotective effects. Although, clinical evidence to date hasprovided inconsistent results and suggests that raising HDL levels may not be the straight‐forward answer to atheroprotection [79,80]; HDL-based therapies, also combined with otheratheroprotective strategies, may be a valide future atheroprotective approach.


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16. Conclusion

As a result of increased understanding of the characteristics and production of ROS andoxidative stress and demonstrated a link either directly or indirectly to atherosclerosis, thereduction of ROS or decreasing their rate of production may delay the onset and progres‐sion of atherosclerosis. Aging promotes physiological changes, such as oxidative stress, in‐flammation and endothelial dysfunction strictly associated with the pathophysiology ofatherosclerosis. Actually, compelling evidence indicates that increased consumption ofcorrect diet containing nutritive and non-nutritive compounds with anti-oxidant proper‐ties may contribute to the improvement of the quality of life by delaying onset and reduc‐ing the risk of CVDs and, in particular, the development of an atheroprotective strategiesacting on oxidative stress involved in the pathogenesis of atherosclerosis and with littletoxicity or adverse effects may provide an ideal simil-therapeutic treatment against athero‐sclerosis. Actually, cardiovascular prevention and treatment strategies should consider thesimple, direct and inexpensive dietary approach as a first line approach to the burgeoningburden of CVDs, alone or in combination with pharmacological treatments. In this con‐text, wine, tea, fruit and olive oil received much attention, because they are particularlyrich in natural anti-oxidants.

However, a better understanding of the oxidative stress-dependent signal transductionmechanisms, their localization, and the integration of both ROS-dependent transcriptionaland signaling pathways in vascular pathophysiology is anyway a prerequisite for effectivepharmacological and non pharmacological interventions for cardiovascular protection fromoxidative stress.

In conclusion, the proposal that anti-oxidants may retard the progression of atherosclerosisis very interesting and promising, but further studies are needed to better understand themechanisms that underline the biological effect of healthy life style.

Acknowledgments

Sincerely thank to Ferrarelle S.r.l. and Chronolife S.r.l. for the support of this study.

Author details

Luigi Fabrizio Rodella and Gaia Favero

*Address all correspondence to: [email protected]

Human Anatomy Division, Department of Biomedical Science and Biotechnology, Universi‐ty of Brescia, Italy


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